First Phase of Medicare Chiropractic Demonstration Project Concludes

Profession Awaits CMS Analysis, Expected by Spring 2009

By Tina Beychok, Associate Editor

As of March 31, 2007, the groundbreaking Centers for Medicare & Medicaid Services (CMS) Chiropractic Demonstration Project, designed to evaluate the feasibility of expanding chiropractic within the Medicare system, has drawn to a close.

Established in 2004 as part of the Medicare Prescription Drug, Improvement and Modernization Act, the demonstration project officially began on April 1, 2005, with the clinical phase designed to last two years.

The project provided for the provision of a variety of chiropractic services in five states: Illinois (26 counties), Iowa (one county), Maine, New Mexico and Virginia (17 counties). Language contained in the Medicare Prescription Drug, Improvement and Modernization Act also required the Secretary of Health and Human Services to conduct an evaluation of the project, including cost-effectiveness, cost-benefit, Medicare beneficiary satisfaction, and "such other matters" as deemed appropriate.

In 2004, at a press conference announcing the project, then-CMS Administrator, Dr. Mark McClellan, explained the rationale for evaluating chiropractic services within the Medicare system: "We recognize that many Medicare beneficiaries seek the services of chiropractors for back pain and other conditions. This demonstration provides the opportunity to evaluate whether expanding coverage of chiropractic services reduces overall Medicare expenditures for neuromusculo-skeletal [NMS] conditions."

Under current Medicare rules, chiropractic coverage is limited to the provision of only one service: manipulation of the spine to correct a subluxation or malformation. Under terms of the demonstration project, patients did not require approval from another health care provider before receiving chiropractic care. The project allowed chiropractors to provide services to any beneficiary enrolled under Medicare Part B, and included expanded coverage for services used to treat NMS disorders, including X-rays, diagnosis, and other therapies.

Formal details of the project were outlined in the Jan. 28, 2005 issue of the Federal Register. The notice detailed five guidelines regarding the types of chiropractic services that could be delivered as part of the demonstration:

Services must be related to active treatment of a neuromusculoskeletal disorder, not maintenance or prevention. All claims under the demonstration are required to have the active therapy modifier.

The demonstration will expand the services chiropractors are allowed to provide, but only for the treatment of neuromusculoskeletal conditions. Among the services chiropractors can provide are plain X-rays, electromyography tests, nerve conduction studies, magnetic resonance imaging (MRI) scans, and computed tomography scans. Chiropractors also can order or provide laboratory tests, provided they are legally allowed to do so in the state in which they practice.

The demonstration will cover Current Procedural Terminology (CPT) code 98943 for extraspinal manipulation, which is a recognized procedure for the treatment of musculoskeletal conditions. The project also will expand coverage to include other services chiropractors are legally allowed to provide and that Medicare currently covers, including electrotherapy, ultrasound, transcutaneous electrical nerve stimulation therapy, and other "medically necessary" services for the treatment of musculoskeletal conditions.

DCs delivering the above services will be subject to the same payment policies as other Medicare clinicians who deliver these services. Chiropractors also will be reimbursed for evaluation and management (E&M) services delivered for neuromusculoskeletal conditions. Under the project's guidelines, chiropractors would be allowed to bill Medicare for treatment in addition to an E&M visit on the same day, the first time they assess a patient, and thereafter only when assessing a patient for a new, separate problem not currently being treated.

Chiropractors are required to submit claims for demonstration services separately from claims for currently covered services, and will have to add a demonstration code to all demonstration claims in order to receive reimbursement.

Per the Medicare Prescription Drug, Improvement and Modernization Act, the project now enters a second phase, during which CMS will collect and evaluate all of the claims data generated in the first phase. This process is expected to last another two years. CMS will provide Congress with a formal analysis and report of the findings in the spring of 2009. No additional chiropractic services will be covered under Medicare during this phase.

"Upon completion of the Medicare Chiropractic Demonstration Project, the chiropractic profession should have solid and reliable data on which to build our case for a permanent expansion within Medicare," said Dr. Richard Brassard, president of the American Chiropractic Association (ACA). "If the data are favorable, it will be the pathway to enacting a law that will win us the Medicare coverage we have sought for years. The results of the demonstration project could finally mean the end of 30 years of discrimination against millions of patients who have been denied needed chiropractic care for far too long - not only under Medicare, but also under many private insurance plans that use Medicare as a model."

In the meantime, the ACA is continuing to urge all DCs to focus on improving the chiropractic care documentation error rate within the Medicare system. The ACA fears that high claims error rates among chiropractors may jeopardize chances for chiropractors to be allowed to perform additional services under Medicare, even if results from the demonstration project are favorable. Guidelines on ensuring proper documentation are available for viewing on the ACA Web site at www.acatoday.org/medicare.

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